Evaluation of the sexual function of men in Kazakhstan during 2021–2022: A cross‐sectional study

Abstract Background and Aims Assessing male sexual function is an important public health issue in every country. In Kazakhstan, there are currently no reliable statistics on male sexual function. The study aimed at the assessment of sexual function in men in Kazakhstan. Methods Men between the ages of 18 and 69 from Astana, Almaty, and Shymkent, three of Kazakhstan's biggest cities, were included in the cross‐sectional study in 2021–2022. A standardized and modified Brief Sexual Function Inventory (BSFI) tool was used for participants' interviews. The World Health Organization STEPS questionnaire was employed to gather sociodemographic information, including smoking and alcohol use. Results Respondents from three cities: n = 283 from Almaty, n = 254 from Astana, and n = 232 from Shymkent were interviewed. All participants' average age was 39.2 ± 13.4. Kazakhs made up 79.5% of the respondents by nationality; 19.1% who answered questions on physical activity verified that they were involved in high‐intensity labor. According to the BSFI questionnaire, the respondents from Shymkent had an average total score of 2.82 ± 0.92, (p ≤ 0.05), which was higher than the total scores of respondents from Almaty (2.69 ± 0.87) and Astana (2.69 ± 0.95). A relationship was found between sexual dysfunction and age indicators over 55 years. Participants with overweight had a relationship with sexual dysfunction with an odds ratio (OR): 1.84 (p = 0.01). According to the smoking factor, in study participants with sexual dysfunction, a relationship was also determined, OR: 1.42; 95% confidence interval (CI): 0.79–1.97 (p = 0.001). The presence of high‐intensity activity (OR: 1.58; 95% CI: 0.04–1.91), and physical inactivity (OR: 1.49; 95% CI: 0.89–1.97) were associated with the presence of sexual dysfunction, p ≤ 0.05. Conclusions Our research indicates that men over 50 who smoke, are overweight, and are physically inactive are at risk for sexual dysfunction. Early health promotion may be the most effective method to reduce the negative effects of sexual dysfunction on the health and wellbeing of men over 50.

may be the most effective method to reduce the negative effects of sexual dysfunction on the health and wellbeing of men over 50.

K E Y W O R D S
aging, erectile dysfunction, population-based research, sexual dysfunction, sexual satisfaction

| INTRODUCTION
One of the most important aspects of life is sexual function, which has a significant impact on the body, mind, social behavior, and quality of life. 1 In fact, problems with sexual function may lead to psychosocial issues, lowering work productivity, and a decrease in quality of life.
Most of the published reports in this area have been focused on the evaluation of specific diagnostic and therapeutic strategies. 2 However, wide population-based studies have not been conducted in developing countries, particularly in Central Asia and Kazakhstan. The need for large-scale studies of sexual function in various Asian populations may help determine not only risk factors but also the effectiveness of the treatment of male sexual dysfunction. 3 The use of a short questionnaire to assess sexual function in men has proven useful in some studies. 4,5 The Male Sexual Function

Inventory (Brief Sexual Function Inventory [BSFI]) was published by
O'Leary et al. 6 The questionnaire is a concise, self-administered, and clinically useful tool for this kind of epidemiological research. 7 Sexual dysfunctions are a group of disorders that are typically characterized by clinically significant disturbances in response to sexual pleasure. 8 Thus, the BSFI tool and overall BSFI score can be useful for finding strong correlations between functional areas and comprehensive analysis. 9 Depending on factors such as culture, race, and health, different countries have varying incidence rates for sexual issues. 10

| Study subjects
The study was conducted in the period 2021-2022. This crosssectional study included men aged 18-69 from three major cities in Kazakhstan (Astana, Almaty, and Shymkent). Participation in the study is completely voluntary.
The fundamental goal of the sample design is to ensure that the indicators measured represent the state of the nation as a whole and that the sample is national in scope and coverage. Using a multistage sampling technique, a list of every polyclinic medical facility in a given city was compiled as part of the sampling procedure. The sample included men who visited a polyclinic at their place of residence as part of a preventive examination. Systematic random sampling was used to recruit no more than 30 people per day from each polyclinic.

| Inclusion criteria
Men population only aged >18 were included (age from 18 to 69); residents of three following cities: Astana, Almaty, and Shymkent; agreement for participation.

| Exclusion criteria
Population permanently residing in the following premises and locations: boarding schools (orphanages), specialized institutions for minors in need of social assistance and rehabilitation, social service institutions, hospitals, and other healthcare organizations, the barracks; buildings owned or transferred to the use of religious organizations, prisons, correctional institutions or medical and labor dispensaries, and persons without a permanent residence.

| Data collection
Participants were interviewed using the standardized and adapted BSFI tool. 11 In addition, we collected sociodemographic data (including smoking and alcohol) using the STEPS WHO questionnaire. 12 The BFSI is a qualified sexual functioning self-report meter. The indicator covers sexual desire and satisfaction, erectile function, and ejaculatory function, as well as an assessment of the problems of desire, erection, and ejaculation. The BSFI is a self-administered 11-item questionnaire in which the first 10 items cover functional aspects of male sexuality such as sexual desire (2 items), erection (3 items), ejaculation (2 items), and 3 points focus on how problematic these aspects are for patients. The last point covers all kinds of sexual satisfaction. 2 Respondents were asked to report their experiences in the last 30 days. Because the BFSI validates the spectrum of sexual activity, it does not generate any points. Most likely, each domain is considered separately. 13 The element's scaling ranges from 0 (no feature, big problem, etc.) to 4 (good feature, no problem, etc.); the overall score is calculated by summing the item's scores. Low scores mean poorer function. 14 STEPS is a WHO standardized but flexible system for monitoring major noncommunicable disease risk factors for countries through questionnaires and physical and biochemical measurements. It is coordinated and supervised by the national authorities of the implementing country. STEPS surveys are typically household-based and conducted by interviewers using scientifically selected samples. 15 The BSFI questionnaire was translated by two reproductive health experts fluent in English, Russian, and Kazakh into two languages (Russian and Kazakh) (Appendixes A1 and B1).
The BSFI and STEPS WHO questionnaires were uploaded to the "HealthTrack" mobile application (https://apps.apple.com/kz/app/ health-track/id1589077331) for further use by the interviewers. All interviewers who conducted the survey were GCP certified.

| Statistical analysis
Statistical analysis was conducted using SPSS software (version 25.0; IBM SPSS Inc.). The results are presented as M ± SD. Qualitative characteristics were described in absolute (n) and relative values (%). BSFI internal consistency was assessed using Cronbach's α test. Multivariate logistic regression was performed for the analysis of risk factors for sexual dysfunction (overall satisfaction rate ≥2x points), and p < 0.05 was considered statistically significant for all analyses. Analysis of variance was chosen for the statistical test, as the samples from the groups were independent. Tukey's honestly significant difference for the unequal test was used to test for pairwise differences because there was a difference in the number of patients in each group. Univariate analysis was adjusted for age and gender. The χ 2 test was used to establish the statistical significance of differences between groups.
Depending on the language of the survey, n = 513 (66.7%) participants preferred to use the questionnaire in Russian, while n = 256 (33.3%) respondents used the questionnaire in Kazakh.
The general characteristics of the participants included in the study (n = 769) are presented in Table 1. Among all participants, respondents in the age group of 18-24 years and 35-39 years were n = 113 (14.7%) and n = 112 (14.6%), respectively. The number of participants in the age category 3 was equal to n = 110 (14.3%).
Among the respondents, the smallest share was made up of respondents of the age group of 60-64 years and 65 years and older, in n = 38 (4.9%) and n = 34 (4.4%) cases.
In terms of educational attainment, the overwhelming majority in According to marital status, n = 536 (69.7%) of the respondents were married, and in slightly more than ¼ in n = 194 (25.2%) cases, the respondents were single. n = 24 (3.1%) of the participants indicated that they were divorced, and n = 6 (0.8%) respondents indicated that they were married but separated.
By type of employment, the vast majority of the interviewed men in n = 358 (46.6%) were employees of the private sector, and n = 83 (10.8%) of the participants were civil servants. n = 102 (13.3%) of the respondents were entrepreneurs, and n = 51 (6.6%) were state employees. Students and pensioners accounted for n = 48 (6.2%) and n = 46 (6.0%), respectively. Among the respondents, the unemployed, able to work amounted to n = 62 (8.1%), and the unemployed, unable to work were equal to n = 11 (1.4%).
Smoking of any tobacco products was currently confirmed by n = 224 (29.1%) and denied by n = 545 (70.9%) of respondents.
Among the respondents, n = 416 (54.1%) respondents did not drink alcohol. While the number of participants who consumed alcohol in the last 30 days equal to n = 204 (23.4%) was higher compared to n = 149 (19.4%) nondrinking respondents.
In terms of physical activity, n = 147 (19.1%) respondents confirmed the presence of high-intensity activity, in which breathing or heart rate increases significantly (e.g., weight lifting, field, earthwork, or construction work) and which lasts continuously for at least 10 min, and n = 622 (80.9%) denied.
Among respondents who confirmed high-intensity physical activity, n = 41 (5.3%) respondents spent 7 days in a typical week doing high-intensity physical activity at work, and n = 34 (4.4%) 5 SIKHYMBAEV ET AL. | 3 of 10 T A B L E 1 General characteristics of the participants included in the study (n = 769). The presence of high-intensity work in which breathing or heart rate increases significantly (e.g., heavy lifting, field, earthwork, or construction work) and which lasts continuously for at least 10 min The results of checking the reliability of the questionnaire are presented in Table 2. The reliability of individual questions was almost the same. Cronbach's α was 0.791 for the total score.

| DISCUSSION
To the best of our knowledge, this is the first study examining the sexual function of male participants using tools specifically designed to assess male sexual function in the three biggest cities of Kazakhstan.
According to the results acquired, it was revealed that the prevailing majority of participants (44.1%) had higher education. In a previously published study, it was indicated that men with a college education had a lower tendency to develop erectile dysfunction compared to those who did not have a high school diploma, but this decrease was not statistically significant. One explanation was that higher education is an indicator of higher socioeconomic status, which is associated with positive lifestyle factors and better access to health care. 16 By nationality, among all n = 769 respondents, in n = 611 (79.5%) cases, the respondents were Kazakhs, and n = 78 (10.1%) Russians.
By marital status, the vast majority of 69.7% of respondents were married.
As a risk factor, smoking any tobacco products was confirmed by Since sexual dysfunction is a complex set of symptoms, doctors should diagnose the underlying pathologies, and risk factors that can lead to it, instead of focusing only on finding a cure. 17 The use of the BSFI questionnaire was justified in view of the fact that Cronbach's α was 0.791 for the total score, indicating the applicability and validity of this questionnaire in this study. In our study, according to the results of the survey, in general, for all three cities, the average indicators of the sexual drive were 2.38 ± 0.12, erections 2.79 ± 0.57, ejaculations 3.03 ± 0.76, problem assessment 2.93 ± 0.88, and overall satisfaction 3.08 ± 0.74.
According to the results of the survey on the BSFI questionnaire, the respondents from Shymkent had an average total score on the BSFI questionnaire of 2.82 ± 0.92, (p ≤ 0.05), which was higher than the total scores of respondents from the cities of Almaty (2.69 ± 0. 87) and Astana (2.69 ± 0.95).
Sexual function is known to decline with age. 18 The findings indicated that among study participants who scored below ≤2 points according to the BSFI survey, a statistically significant relationship was found between sexual dysfunction and age indicators over 55 years.
According to some reports, the frequency of sexual dysfunction increases not only with age, but can also be associated with a number of diseases, such as diabetes, tobacco abuse, metabolic syndrome, cardiovascular disease, and obesity. 19 We observed a direct statistically significant relationship between overweight (BMI > 30) and sexual dysfunction (p = 0.01).
These data are consistent with the results of previous studies, where it was assumed that an obese man has the same degree of sexual dysfunction as a nonobese man, about 20 years older in age. 13 In addition, in the Massachusetts Male Aging Study, the overall prevalence of erectile dysfunction was 17%, but it increased to 45% in subjects with BMI values of 30 kg/m 2 . 20 Despite the fact that the reason for the influence of excess weight on the manifestation of T A B L E 4 Multivariate logistic analysis by dysfunction, that is, those with an overall average score below 2 (≤2 points). sexual dysfunction in men is still not completely clear, there are some suggestions of a connection with a decrease in the concentration of free and total testosterone in the blood serum and a decrease in sex hormone-binding globulin in obese men. Moreover, the rate of estrogen production can also elevate with increasing obesity, possibly due to the activation of androgens by adipocytes. 21 Smoking, as a possible risk factor, also showed a statistically significant association with sexual dysfunction in our study participants who scored below ≤2 on the survey (OR: 1.42; 95% CI: 0.79-1.97). This is also consistent with the results of a previously published meta-analysis of more than 28,000 participants, which found that compared with nonsmokers, the OR risk of developing erectile dysfunction in cohort prospective studies was 1.51 (95% CI:  23 According to some reports, this can be associated with the effect of nicotine on increasing the tone of the sympathetic nervous system, which causes vasoconstriction and thereby reduces blood flow to the penis, and nicotine contributes to endothelial dysfunction, which worsens erectile function. 16 The results of some national studies showed the relationship between an increase in the chances of developing sexual dysfunction in men, depending on race/ethnicity. 24 However, in our study, according to such parameters as nationality, marital status, a causal relationship with sexual dysfunction was not determined (p > 0.05).
The presence of high-intensity activity in the study participants had a statistically significant relationship with the development of sexual dysfunction (p = 0.04).
Hypodynamia also had a relationship with the presence of sexual dysfunction, which was regarded as a statistically significant difference (p = 0.01). Literature review shows that sexual dysfunction in middle-aged men is often an early manifestation of endothelial damage, and physical activity can improve both erectile and endothelial dysfunction. 17 In a previously published study, it was noted that intense and moderate physical activity is associated with a lower risk of developing erectile dysfunction. It increases endothelial NO production and reduces oxidative stress and levels of inflammatory markers, including proinflammatory cytokines and C-reactive protein. 25 The results of a prospective, randomized study in Italy in moderately obese sedentary men demonstrated the role of lifestyle changes (weight loss, physical activity) in reversing erectile dysfunction.
Since sexual problems have a direct and indirect impact on various aspects of life, it is necessary to educate people to identify, diagnose, treat, and prevent such dysfunctions. The vast majority of risk factors for sexual dysfunction in men, such as smoking, physical inactivity, and obesity, are modifiable. 25 Therefore, it is necessary to pay attention to preventive measures to eliminate these risk factors.

| CONCLUSIONS
We were able to identify the indicators that are important for the prevention of sexual dysfunction in men. The various risk factors were evaluated using an adjusted BSFI questionnaire. According to our findings, males who are over 50, smoke, are overweight, work at high intensities, are inactive, and are also at risk for sexual dysfunction.
Early initiation into a healthy lifestyle may be the best approach to reduce the burden of sexual dysfunction on the health and wellbeing of men over 50 years of age. Further ongoing community programs are needed to highlight the importance of addressing sexual dysfunction, decreasing smoking, and educating on the importance of physical activity.

| Study limitations
This study has a few limitations. Due to the inclusion of respondents from only three cities in this study, the sample size of participants was insufficient. In addition, some laboratory parameters, such as testosterone levels and other hormones, were not covered by this study. Aside from that, due to the survey methodology, the presence of the level of sexual dysfunction of the study participants was based only on the answers of the respondents, without verification of this pathology by a urologist.